Korean J Crit Care Med 2014 August 29(3):222-225 / http://dx.doi.org/10.4266/kjccm.2014.29.3.222 ISSN 2383-4870 (Print)ㆍISSN 2383-4889 (Online)
■ Case Report ■
Cardiogenic Shock in a Patient with Intermediate Coronary Artery Disease due to Preoperative Spasm Donghun Shin, M.D., Min-jin Lee, M.D., Chul-hong Park, M.D., Joongkeun Kim, M.D., Dae-sung Lee, M.D., and Jun-Hyok Oh, M.D.* Departments of Internal Medicine and *Cardiology, Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
The best management strategy for angiographically intermediated coronary artery diseases remains controversial. Lesions, when coupled with spasm, can lead to catastrophic results and cardiogenic shock. We report a case of a 62-year-old man who had an intermediate coronary artery disease presenting with cardiogenic shock due to coronary spasm during a preoperative period. Key Words: coronary artery disease; coronary vasospasm; perioperative period.
When an intermediate coronary artery disease (CAD) is re-
assessment prior to gastrectomy for advanced gastric cancer. He
vealed on coronary angiography (CAG), making a decision on
was a smoker with a history of hypertension. His left ventricular
how to treat as well as preparation for non-cardiac surgery is
systolic function was normal without abnormality in the region-
challenging. Prophylactic revascularization is supported only in
al wall motion. He had atypical, effort-unrelated substernal
the case of severe extensive ischemia.[1,2] Inducible ischemia
chest pain, and it was difficult to assess his functional capacity.
caused by an intermediate CAD would be worsened when cou-
Consequently, we prepared a coronary angiography to determine
pled with spasm. If we miss the possibility of variant angina pec-
latent unstable angina pectoris, and the coronary angiography
toris in the patient who have intermediated CAD, using routine
showed intermediate coronary artery disease (stenosis diameter
beta-blocker can be dangerous. We present a case of cardiogenic
64% by Quantitative coronary angiography) (Fig. 1A). The pa-
shock in a patient with an intermediate CAD in the preoperative
tient was discharged without coronary intervention with a plan
exam, and who had been previously deferred for revascularization.
to undergo gastrectomy while being medicated with statin, low dose β-blocker (bisoprolol hemifumarate 2.5 mg qd), calcium
Case Report
channel blocker (amlodipine besylate 5 mg qd), and nitrate (isosorbide-5-mononitrate 20 mg bid). The following day, he was readmitted with worsening chest pain after drinking alcohol, and
A 62 year-old Korean man was referred for perioperative risk
rapidly deteriorated into cardiogenic shock. The electrocardiogram (ECG) showed ST-segment elevation in leads II, III, and Received on April 4, 2014 Revised on May 28, 2014 Accepted on June 9, 2014 Correspondence to: Jun-Hyok Oh, Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Pusan National University College of Medicine, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea Tel: +82-51-240-7794, Fax: +82-51-240-7796 E-mail:
[email protected]
aVF, and ST-segment depression in leads I, aVL, and precordial leads, with junctional escape rhythm (Fig. 2A). Ventricular fibrillation occurred at the arrival to the catheterization laboratory, and it was reverted by defibrillation shock. The coronary angiography via right femoral artery revealed total and simultaneous occlusions at the proximal segment of both the left descending artery (LAD) and the left circumflex artery (LCX) (Fig. 1B). We as-
* No potential conflict of interest relevant to this article was reported.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright ⓒ 2014 The Korean Society of Critical Care Medicine
222
Donghun Shin, et al. Coronary Spasm in Preoperative Period 223
A
B
C
D
E
F
Fig. 1. Coronary angiogram and percutaneous coronary intervention are shown. (A) Left coronary angiogram before cardiogenic shock is shown. (B) Left coronary angiogram after cardiogenic shock is shown. (C) Diffuse spasm in downstream vessel after wiring into the Left anterior descending coronary artery is shown. (D) Placing a bare metal stent is shown. (E, F) The right coronary angiogram is shown before and after cardiogenic shock. Arrows in (A-C) and (F) indicate lesions. Arrow in (D) points to stented segments.
sessed that multivessel spasm could even trigger cardiogenic shock and the total occlusion of the distal right coronary artery (RCA), and it was found that the LCX and a total occlusion of the LAD had arisen in this patient. An intra-aortic balloon pump was inserted via the left femoral artery, and intracoronary nitroglycerin of 200 µg was administered. After wiring into the LAD,
A
balloon inflation (Ryujin® 2.5 × 10 mm, Terumo, Japan) was performed in the proximal LAD where the intermediate stenosis from the previous angiography was found. The subsequent angiography showed a diffuse spasm in downstream vessel (Fig. 1C). However, the patient was in a state of cardiogenic shock and it was intractable to inject intracoronary nitroglycerin and to inflate the balloon. Therefore, we decided to insert stent using a bare metal stent (Multi-Link Vision®, 3.5 × 18 mm; Abbott Vascular,
B Fig. 2. (A, B) Pre- and post-procedure of resting 12-lead Electrocardiogram.
USA) (Fig. 1D). Comparing to the previous angiography (Fig. 1E), the right coronary angiography following the intervention of the LAD revealed multi-segments spasm (Fig. 1F). To resolve a cardiogenic shock after stent insertion, we administered several times the intracoronary nitroglycerin injection, and then, ST-seg-
224 The Korean Journal of Critical Care Medicine: Vol. 29, No. 3, August 2014
ment changes and rhythm were restored (Fig. 2B). The patient
ficult to avoid. There was a case in which the stent implantation
was treated with calcium channel blocker, nitrate, nicorandil, and
provoked spasm.[9] Although implantable cardioverter defib-
statin, as well as aspirin and clopidogrel. The intra-aortic balloon
rillators are often recommended in some of the patients with ma-
pump was removed the next day. He was discharged. He under-
lignant arrhymias from intractable spasm, no agreement exists
went uneventfully 42 days after the coronary intervention with-
concerning the validity of this treatment.[6] In this case, the pa-
holding clopidogrel for 5 days before the planned gastrectomy
tient with already known intermediate coronary disease pro-
surgery.
gressed into cardiogenic shock due to intractable vasospasm, so we decided to use stenting. This case highlights the potential for diffuse, generalized vaso-
Discussion
spasm occurring in patients during preoperative period. Thus, physicians should consider coronary vasospasm in the differ-
Prophylactic revascularization before a non-cardiac surgery is
ential diagnosis in the course of perioperative risk assessment.
recommended only for those who have severe extensive ischemia
Coronary vasodilators, such as nitrates and/or calcium channel
or are in unstable cardiac conditions.[1,2] When the patient has
blockers, are preferable to β-blockers in such cases.
an intermediate CAD and atypical symptoms, as in the present case, the decision of whether or not to treat can be very difficult. If a patient is not in an unstable cardiac condition, management
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